II. Management: Prehospital and Home interventions for patients prior to presentation
- Immediately remove any items that may cause further injury
- Remove all clothing, jewelry, Contact Lenses
- Stop any ongoing burning
- Remove any clothing involved in scald burn
- Remove all clothing involved in chemical burn (removed with Eye Protection, gloves and other PPE)
- Remove all rings, belts, watches and other items that may cause Tourniquet-type effect
- Place the wound site under cool Running water (46 to 77 F, 8 to 25 C) for 20 minutes (minor Burn Injury only)
- May reduce Burn Injury depth and allow for faster healing with less scar
- Benefits may be limited to the following one hour
- Do not immerse the burn in ice water (Vasoconstriction related tissue injury risk)
- However cool burn with water
- Risks further injury and Hypothermia
- Following wound cooling
- Do not break Blisters
- Do not apply any topical medications to burn site prior to evaluation
- Cover the wound with a clean, dry dressing
III. Management: General Pointers
- Use Opioids intravenously (avoid intramuscular use)
- Administer adequate analgesia to allow for assessment, cleaning and dressing of wounds
- Avoid antibiotics until infection occurs
- Administer tetanus Vaccination
- Indicated if patient has not had at least 3 dose Primary Series AND Tetanus booster in last 5 years
- Staff should wear Personal Protective Equipment (masks, Eye Protection, gloves) in suspected chemical burn
- Remove all clothing from patient
- Precautions and Decontamination as directed by Hazard Safety Data Sheets or Poison Control
- Do not cover burns with Silvadene if transporting
- Obscures lesions for primary burn team
- Burn team will apply Silvadene after their evaluation
- Bacitracin may be applied
IV. Management: Initial
-
Trauma Primary Survey
- Assess airway Inhalation Injury
- See Smoke Inhalation for Endotracheal Intubation indications
- Assess airway edema (intubate if suspect unstable airway)
- Arterial Blood Gas (ABG)
- Carboxyhemoglobin
- Dive Chamber indicated for level >40
- Remove all clothing, jewelry, Contact Lenses
- Stop any ongoing burning
- Cover injured areas after evaluation to prevent overall body heat loss
- Assess airway Inhalation Injury
-
Trauma Secondary Survey
- Assign Burn Injury grading and surface area involved
- Assess other injuries
- Evaluate for signs of intentional injury (e.g. abuse)
- Consider Smoke Inhalation and complications (Carbon Monoxide Poisoning, cyanide Poisoning)
- Evaluate for Compartment Syndrome requiring Escharotomy
- Escharotomy may be deferred to Trauma surgery if good doppler pulse on Ultrasound at transfer time
- Compartment Syndrome onset >2 hours after Burn Injury (typically 4-6 hours)
- Assess Fluid status
- Urine Output minimums
- Adult: 0.5 ml/kg per hour (typically at least 30-50 cc per hour)
- Child: 1 cc/kg per hour
- Intravenous requirements for insensible loss (Parkland Formula, aka Consensus Formula)
- Parkland formula applies to burns encompassing >20% BSA
- First Degree Burn area does not count toward percent burn area or fluid volume
- Administer 2-4 ml crystalloid (NS or LR) per kg per %BSA
- Lactated Ringers (LR) is preferred to avoid hyperchloremic Metabolic Acidosis
- Volume requirements over first 24 hours may be as much as 10-20 Liters
- No initial fluid bolus is needed unless hypotensive
- Exercise caution in burn percentage calculation, esp. in children (overestimated by >200%)
- Excessive Fluid (Fluid Creep) is associated with worse outcomes (e.g. Sepsis, ARDS)
- Goverman (2015) J Burn Care Res 36(5): 574-9 +PMID:25407387 [PubMed]
- Lactated Ringers (LR) is preferred to avoid hyperchloremic Metabolic Acidosis
- Divide rehydration over 24 hours
- Give 50% over first 8 hours since burn
- Give second 50% over next 16 hours
- Parkland formula applies to burns encompassing >20% BSA
- Urine Output minimums
V. Management: Wound Care
- Avoid scrubbing the wound with antiseptics (e.g. Betadine, Peridex, Hibiclens)
- Use sterile saline or sterile water to clean the wound and eliminate debris
-
Blisters
- Blister fluid contains both Cytokines that cause inflammation, but also growth factors to speed healing
- Indications to debride
- Blister debridement approach
- Unroof Blister with sterile scissors
- Clean wound with chlorhexidine or similar mild antibiotic soap
- Cover wound with ointment and nonadherent dressing
- Indications to NOT debride
- Escaharotomy Indications
- Background
- Escharotomy incisions are performed to depth of subcutaneous fat, avoiding vital structures
- Goals
- Impoved perfusion, sensation, motor activity, compartment pressures, doppler pulses
- Improved ventilation (chest Escharotomy)
- Compartment Syndrome
- Associated with Third Degree Burn injury to extremities (esp. circumferential)
- Escharotomy is most likely to be required in first 2-6 hours after Burn Injury
- Performed with lateral and medial incisions from 1 cm proximal to 1 cm distal ends of Burn Injury
- Chest wall burns may also require Escharotomy due to limiting respiration
- Performed with a vertical incision from clavicle to inferior costal margin, mid-axillary line (avoiding Breast)
- Background
VI. Management: Topical agents
- Avoid Topical Corticosteroids
- Approach
- Goal is to maintain moist healing environment and prevent infection
- Administer Analgesics 30 minutes before dressing changes
- Method 1: Typical approach
- Apply topical agent (e.g. Bacitracin) with simple dressing that is changed every 12-24 hours
- Monitor for wound progression and infection
- Method 2: Burn center or wound care directed
- Apply advanced dressing (e.g. silver impregnated foam) for up to 14 days
- Topicals for superficial burns (first degree)
- No treatment needed (will heal without intervention within 1 week)
- Aquaphor
- Bacitracin ointment
- Sterile Medical-Grade Honey (avoid typical honey as it contains Botulism and other organisms)
- Aloe vera (may reduce pain)
- Topical NSAID (e.g. Diclofenac Gel, may reduce pain)
- Topicals for deeper burns (second and Third Degree Burns)
- Topical Antibiotics
- Bacitracin ointment
- Preferred initial topical agent in most cases
- Mupirocin (Bactroban)
- Used for MRSA prone regions (e.g. facial burns around the nose)
- Mafenide acetate (Sulfamylon)
- Used for deep burns even if eschar present
- Silvadene (Silver Sulfadine, SSD)
- Do not apply if Transferring patient to burn center (obscures wound)
- Preferred in Third Degree Burns
- Other agents are preferred for Second Degree Burns
- Silvadene inhibits Keratinocyte replication and delays healing and increases scar risk
- Wasiak (2013) Cochrane Database Syst Rev 3:CD002106 +PMID:23543513 [PubMed]
- Contraindicated in Sulfa Allergy, G6PD, pregnancy and Lactation and newborns
- New Occlusive Dressings may offer faster healing, less pain and lower cost (e.g. Aquacel Ag)
- Bacitracin ointment
- Absorptive Dressings
- Aquacel Ag
- Less pain and healing time as well as less frequent dressing changes
- Lower total cost than Silvadene
- Broad spectrum antibacterial coverage
- Hydrocolloid Dressings (Duoderm, urgotul)
- Form gel when moisture is present (absorbs exudates)
- Less pain and healing time
- However dressing has an odor and obscures visualization of the wound site
- Alginate Dressings
- Seaweed derived absorbtive dressings
- Aquacel Ag
- Nonabsorptive dressings
- Nonadherent gauze (e.g. Vaseline Gauze)
- Inexpensive dressing used for superficial burns; lacks antibacterial coverage
- Silicone (Mepitel)
- Expensive dressing that allows wound seepage to pass through to overlying bandage
- Silver Impregnated dressing (e.g. Acticoat)
- Expensive non-adherent dressing that has broad spectrum antibacterial coverage
- Foam Pads (e.g. Optifoam)
- Barrier protection of wound site
- Nonadherent gauze (e.g. Vaseline Gauze)
- Miscellaneous dressings
- Biocomposite or biosynthetic (e.g. Biobrane)
- Silicone membrane with nylon mesh
- Efficacy limited to superficial burns and is expensive
- Bioactive skin substitute (e.g. Trancyte)
- Expensive, but less pain and healing time and allows visualization of burn through the dressing
- Biocomposite or biosynthetic (e.g. Biobrane)
- Topical Antibiotics
VII. Management: Infection
- Causes
- Staphylococcus aureus
- Streptococcus Pyogenes
- Gram Negative Bacteria (esp. Diabetes Mellitus)
- Pseudomonas aeruginosa
- Acinetobacter species
- Klebsiella species
- Precautions
- Signs of Iinfection may be difficult to distinguish from the original burn inflammation
- Infections at burn sites may progress rapidly
- Fever in first 72 hours of Burn Injury is typically not due to burn-related infection
- Often due to hypermetabolism and may be treated with antipyretics
- Fever after first 72 hours of Burn Injury warrants evaluation and often hospitalization
- Oral antibiotic prophylaxis (e.g. Cephalexin) is NOT recommended in first or Second Degree Burns
- Systemic antibiotics do not modify skin surface flora and do not reduce infection risk
- Systemic antibiotics increase Antibiotic Resistance
- Topical Antibiotics may reduce infection risk
- Burn Injury in Diabetes Mellitus is associated with a high risk of infection (44%) and other complications (90%)
- Foot burn injuries in Diabetes Mellitus are high risk for infection (15%)
- Gram Negative infections are more common in Diabetes Mellitus
- Clinical re-examination of feet every 3-4 days is recommended (or admit for 3-4 day observation)
- Management
- Direct antibiotics coverage to Gram Negatives and Gram Positives based on local Antibiotic Resistance
VIII. Management: Criteria for transfer or referral to burn center
- Partial thickness burns involving more than 10% of total body surface area
- Immediate transfer if partial thickness burn involving 20% BSA (10% if age under 10 or over 50 years old)
- Third degree (full thickness) burns
- Immediate transfer if Third Degree Burn >5% of total body surface area
- Any burns of high risk areas
- Face, eyes or ears
- Hands or Feet
- Genitals or perineum
- Burns over major joints
- Electrical Burns
- Inhalation Injury
- Chemical burns
- Burn Injury with associated Trauma (e.g. Fractures), in which Burn Injury is the most significant of the injuries
- Burn Injury expected to require >2 weeks for healing (reduce Hypertrophic Scar)
IX. Management: Burn-related symptoms
-
Pruritus
- Skin Lubricants
- Cool clothes
- Oatmeal topical preparations
- Cetirizine (Zyrtec)
- Doxepin topically
- Pain
- GI prophylaxis (peptic ulcer prophylaxis)
- Consider H2 Blocker (e.g. Ranitidine) or Proton Pump Inhibitor (PPI) for more hospitalized patients with Burn Injury
X. Management: Follow-up
- Burn reassessment in 48-72 hours
- Even initially minor appearing wounds may significantly worsen with days
- Superficial partial thickness burns may extend to deep partial thickness or Third Degree Burns
- Prevent reinjury to burn sites
- Cover with Sunscreen SPF 50 and avoid direct sunlight on Burn Injury for 2 years
XI. References
- Mason and Yowler in Herbert (2016) EM:Rap 16(4):4-5
- Weir (2020) Crit Dec Emerg Med 34(12): 3-11
- Cuttle (2009) Burns 35(6): 768-75 [PubMed]
- Grunwald (2008) Plast Reconstr Surg 121(5): 311e-9e [PubMed]
- Hettiaratchy (2004) BMJ 328(7452): 1366-8 [PubMed]
- Lanham (2020) Am Fam Physician 101(8): 463-70 [PubMed]
- Lloyd (2012) Am Fam Physician 85(1): 25-32 [PubMed]
- Roberts (2003) Emerg Med News 25(3): 28-31 [PubMed]
- Sheridan (2005) Emerg Care 21(7): 449-56 [PubMed]
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Related Studies
Concepts | Biomedical Occupation or Discipline (T091) |
SnomedCT | 408462000 |
English | burn management, burns managements, burns management, management burns, Burns care (qualifier value), Burns care, Burns management |
Spanish | atención de quemaduras (calificador), atención de quemaduras |